Abdominal Migraine

Sonal Bhatia
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Non-pharmacological Therapy
A correct explanation of the disease process and also the fact that AM rarely persists into adulthood should be given to the families. It is important to emphasize that a dangerous gastrointestinal, renal, metabolic, endocrine or neurologic disease process is absent in these children.
Theoretically, avoidance of triggers may help in a small group of patients; although, evidence is minimal. Russell et al suggested avoidance of triggers viz., stress, travel, prolonged fasting states, exposure to flickering or strobe lights, physical exertion or exercise, and, alterations in sleep patterns [13].
Dietary modifications with increased fiber, reduced lactose and avoidance of certain food items have been proposed by various authors; again evidence is scarce to support these dietary changes. Feldman et al reported a significant benefit when fiber was increased in the diet of 52 children with AM studied by them. They concluded that 50 % of the children in the fiber group had a 50 % reduction in the number of episodes with abdominal pain, compared with only 27% in the control group [14]. Barr and Liebman demonstrated that eliminating lactose in the diet of children with AM, a significant proportion of whom had an abnormal lactose tolerance test, provided a complete symptom resolution [15, 16]. Russell et al also proposed that avoidance of certain food items (‘few-foods or ‘oligo-antigenic’ diet) known to trigger AM is helpful especially in children with frequent attacks (>2 per week) [13]. Most notable items include chocolates, citrus fruits, caffeine, cheese, and colorings.
Other non-pharmacologic options include psychotherapy in particular cognitive behavioral therapy. These therapies involve introducing the child to the concept of pain and the various coping strategies against it. Sanders et al studied forty-three children with recurrent abdominal pain between the ages 7-14 years and randomized them to either the cognitive behavior therapy group or the standard pediatric care group without cognitive therapy group. Clearly, the percentage of pain-free children as assessed by a diary and parents was higher in the cognitive behavior therapy group both at a 6 month and at a 12 month evaluation [17]. Unfortunately, a restricted availability of trained personnel providing cognitive behavior therapy can be a limiting-step for this treatment option.

This is usually considered in children who fail non-pharmacological measures or in those with frequent and disabling symptoms where drug therapy can be combined with the non-pharmacological measures discussed above.
Abortive agents used for AM are similar to those used in migraine headaches and include acetaminophen or ibuprofen which is usually most effective when given early during the attack. Symptomatic treatment with anti-emetics is indicated in those with nausea or vomiting.
The prophylactic agents found useful in AM are those primarily used in migraine headaches in children – beta blockers (propranolol), serotonin antagonists (cyproheptadine, pizotifen) and calcium channel blockers (flunarizine).
A study by Worawattanakul et al concluded that propranolol or cyproheptadine are effective prophylactic agents in majority of the patients with AM [18]. The authors retrospectively reviewed records of 53 patients who underwent treatment for AM for six months or until migraine cycles had stopped. Among the children given propranolol (10-20 mg, 2-3 times daily), 75 % had an excellent response identified as complete cessation of symptoms, 8 % had a fair response which meant persistence of symptoms but milder and less frequent and 17 % had no response. In those treated with cyproheptadine (0.25-0.5 mg/kg/day), 33 % had an excellent response while 50 % had a fair response while the non-responders remained the same at 17 %. 46 % patients in the propranolol group took the medication for less than six months and 50 % in the cyproheptadine group took medication for less than 10 months while rest of the patients in both the groups continued the respective therapy for three years.
Propranolol is typically started at 10 mg divided in two or three daily doses. Propranolol is best avoided in children with asthma as it can cause bronchospasm. Cyproheptadine is used in doses of 2-8 mg divided in two doses; increased appetite, weight gain and sedation are the most common side-effects.
Symon and Russell in a double-blind crossover trial of fourteen children with AM using pizotifen or placebo demonstrated pizotifen to be clearly superior to placebo. Pizotifen which has antiserotonin, antihistamine and anticholinergic activity; and, is widely used in Canada and Europe; was found to be an effective prophylactic drug in 70 % of the children with AM [19]. Some authors have reported continued benefit even after the drug is stopped [20]. Pizotifen is started at 0.5 mg/kg/day and titrated based on the clinical response up to 4-6 mg/day. Common side-effects are similar to cyproheptadine.
Flunarizine, a calcium-channel blocker was found to be a safe, once-daily option for AM prophylaxis in a study by Kothare [21]. Ten children with AM were treated with a mean dose of 7.5 mg/day and were followed up after a mean average of 13 (6-24) months. 61 % reported a reduction in frequency and 51 % a reduction in the duration of the attacks. Flunarizine, not available in the US, is typically given at a dose of 5 mg at bedtime. Common side effects include constipation, weight gain and hypotension.
Small case series report response to valproic acid and triptans. Others report scarce use of topiramate, amitriptyline, verapamil, nadolol, lynesternol (progestin not available in the US), flumedroxone (progesterone derivative not available in the US). The response is believed to be due to similarities in the pathophysiology of migraine and AM [22, 23].

Very little is concluded regarding the treatment of children with AM. Not all children require treatment; especially if the frequency and severity of the episodes does not affect the quality of life or school work. In these cases, in addition, to providing reassurance; risk-benefit ratio of different treatment options should be explained to the family and they should be totally involved in the decision-making process.
Broadly, management of AM is divided into non-pharmacological and pharmacological modalities.


References
Abdominal Migraine Abdominal Migraine 02/13/2016
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